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Indicates sessions with recordings available for purchase.Salvage total laryngectomy following radiation therapy or chemoradiotherapy is known to be associated with a high rate of pharyngocutaneous fistula(PCF) due to the impaired healing capacity of the tissue bed. Numerous techniques have been introduced to minimise wound healing complications and PCF in salvage laryngectomy patients, the most common being a pedicled pectoralis major myofascial/myocutaneous flap as an onlay to bolster the pharyngotomy repair or a fasciocutaneous free flaps (eg: ALT, radial forearm) which is interposed between the pharyngeal mucosa[1][2]. With the improved reliability of free flap surgery, we are reporting on an alternative method of bolstering the pharyngeal repair with an adipofascial radial forearm free flap to act as a bolster overlying the pharyngotomy closure to improve tissue vascularity and reinforce the pharyngeal suture line in this group of previously irradiated patients.
Methods
We conducted a retrospective review of our group of patients treated through Head and Neck Institute in Portland from July 2012- March 2016. A total of 33 patients underwent a total laryngectomy. Twenty out of thirty patients(66.6%) had free flap reconstruction Out of the patients who had a free flap reconstruction, 8/20 patients had their free flap used as an onlay to bolster the pharyngotomy suture line. Exclusion criteria was applied to patients who required reconstruction of pharyngeal mucosa with a skin paddle. Outcomes assessed included wound complications, pharyngocutaneous fistula, and swallow function. All patients have a minimum followup period of 3 months.
Results
Out of the eight patients who were analysed from the cohort study (5 male, 3 female, average age of 63 years old), six out of the eight patients(75%) had previous radiotherapy to the head and neck and laryngectomy was performed as a salvage procedure following failed definitive chemoradiation treatment. All but one patient had a radial forearm adipofascial flap for their onlay reconstruction. One patient had an ALT flap with an external skin paddle used to reconstruct skin defect from a tumour invasion. There were no pharyngocutaneous fistula identified in any of these patients who received an onlay free flap over the pharyngotomy suture line. Average length of hospital stay was 9.7 days (range 7-14 days). There was only one minor wound complication of a peristomal dehiscence that resolved with wound packing and no major wound complications. There was no reported pharyngeal stricture that required dilatation.
Conclusion
From our initial small case series, free vascularized tissue bolster of primary pharyngeal closure in salvage laryngectomy following failed organ preservation treatment is effective in preventing pharyngocutaneous fistula without increased morbidity or prolonged hospital stay. Speech and swallowing results following this technique were comparable to those following total laryngectomy alone. With these promising initial results, it is our institution’s preference now to provide an onlay adipofascial free flap to bolster pharyngeal closures and further reviews in the future with larger number of patients will be conducted to really examine the efficacy and reliability of this method of reconstruction in preventing pharyngocutaneous fistulas.
[1] Paleri V, Drinnan M, van den Brekel MW, Hinni ML, Bradley PJ, Wolf GT, et al. Vascularized tissue to reduce fistula following salvage total laryngectomy: A systematic review. Laryngoscope 2014, Aug;124(8):1848-53.
[2] Patel UA, Moore BA, Wax M, Rosenthal E, Sweeny L, Militsakh ON, et al. Impact of pharyngeal closure technique on fistula after salvage laryngectomy. JAMA Otolaryngol Head Neck Surg 2013, Nov;139(11):1156-62.